Category: Laparoscopic/ Robotic: Renal
Introduction & Objective : The management of staghorn calculi traditionally has been with percutaneous nephrolithotomy; however, patients with horsehoe kidneys can present a unique challenge, due to the anatomic variation and potential complications that can arise from percutaneous access. We present our technique for transperitoneal robotic assisted laparoscopic pyelolithotomy (RALPL) in a horseshoe kidney
74-year-old male with known horseshoe kidney presented with a creatinine of 1.56 mg/dL and a CT scan showing a 4.7 cm partial staghorn stone in the right extrarenal pelvis with moderate hydronephrosis. After discussing treatment option, it was elected to proceed with RALPL using the da Vinci Xi surgical platform. The procedure is detailed in the accompanying video. Patient was placed in the left lateral decubitus position. A 0.035mm ureteral wire was placed into the right ureter via a flexible cystoscope. Four 8 mm robotic ports were placed in the midclavicular line along the lateral edge of the rectus muscle and one 12 mm assistant port was placed in the supra-umbilical location after pneumoperitoneum was established. Robotic instruments included: a Monopoloar scissors (robotic arm 1), a Bipolar forcep (robotic arm 2), and a Prograsp (robotic arm 3). After the colon was mobilized medially, pararenal fat was dissected inferiorly to allow visualization of the renal pelvis. After proper exposure of the proximal ureter, the color of the ureteral wire was seen through the ureteral tissue. Once the renal pelvis was fully exposed, pure cut setting was used to open the renal pelvis. The stone was then removed from the renal pelvis. The ureteral wire was then grasped via the assistant port and a 6 french 26 cm ureteral stent was placed antegrade via the assistant port.
The renal pelvis was then closed using a 3-O vicryl with a SH needle in a running fashion. The renal calculus was then placed into an endocatch bag for removal. A 10 Fr JP drain was then placed, and all trocars were removed under visualization.
The procedure was successfully completed, and postoperative course was uneventful. Total operative time of 101 minutes, with an estimated blood loss of 50cc. Patient was discharged on post-operative day one, after drain was removed. He was seen in clinic 6 weeks postoperatively and at that time patient was doing well and his stent was removed.
RALPL offers a safe and effective alternative to percutaneous nephrolithotomy for management of large renal calculi in patients with horseshoe kidneys.